How to Get Your Kids to Eat
Learning Objectives
 Introduction
 Identify Resistant Eaters
 Assessment and baseline data
 Review oral-motor delays and
treatment strategies
 Review Sensory based Eating
challenges and treatment strategies
 Functional Behavior Assessment and
Behavior Interventions Plans for
mealtimes to address behavioral
issues
Dr. Lori Ernsperger, Ph.D., BCBA-D
www.loriernsperger.com
[email protected]
Copyright 2014 Ernsperger
Copyright 2014 Ernsperger
Recipe For Success!
Learning Objectives
 Behavioral difficulties at
mealtimes
 Conducting a FBA
 Write a feeding behavior plan
 Develop antecedent based
interventions strategies
 Discuss escape extinction
procedures
 It starts with you.
 Be fully present and fully attentive when you are
with the child
 Want the very best for the child and family. Know
that they are doing their best at the moment.
If you make a mistake, try again
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5 Common Characteristics
Resistant Eaters
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Limited Food Selection
 Eats less than 5-20 foods
◦ As little as 1 or 2 foods
• Eating Continuum
• Characteristics
 Selects only foods with a
similar trait
1. Limited Food selection
2. Limited Food groups
3. Anxiety around new foods
4. Food Jags
5. Diagnosed with a DD
◦ Only white foods
 Limited in taste and
texture
◦ Pureed foods only
 Bottle fed or formula past
developmental stage
◦ 24 months
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1
Introduction to Resistant Eaters
Limited Food Groups
 Nutritional deficiencies
 Breads and cereal group
• Prevalence
◦ Carb lovers
– 60-75% of children on the ASD
– 5 Times more likely to have behavioral
challenges at mealtimes
– 80% of children with severe mental
retardation
– 30-45% of typically developing children
– Developmental scale
 May eat some from the
meat group
◦ Chicken nuggets from
McDonalds
◦ Wendy’s French Fries
 Very few fruits or
vegetables
◦ Bananas-sweet
◦ Apples- no skin
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Copyright 2014 Ernsperger
Anxiety and New Foods
Developmental Delays
• Medical and neuromuscular
disorders
– CP and GERD
– Down Syndrome
• Premature at birth
– Window for introducing soft
munchables and solids
• ASD
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Tantrums when introduced to a new food
Strong phobic reaction to new foods
Refuses to approach the table
Gagging or vomiting
Highly sensitive olfactory system
New DSM-5 diagnosis
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Food Neophobia
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Fear of new foods
Typically developing stage for 2-3 year olds
Outgrown by age 5
May linger into adulthood without treatment
Food Neophobia Scale (Pliner and Hobden)
– How did you score?
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Mealtime Activity
Intake Form- Eating Profile
• Review student strengths and weaknesses
• Review sensory and motor needs
• Identify food jags
• Medical Assessment
– Consultation
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Oral-Motor Impairment
Mealtime Plan
• Oral-Motor Based
Interventions
• Sensory Based
Interventions
• Behaviorally Based
Interventions
• Combination
• Caution: stay within
your competency
 Assessment by a highly
qualified OT or SLP
 Definition:
Movements of the
muscles in the mouth,
lips, tongue, cheeks,
and jaw.
 Includes the functions:
biting, crunching,
chewing, sucking, &
licking
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Copyright 2014 Ernsperger
Causation: Oral Motor Skills
• “Sometimes children get “Stuck” in their oral-motor
development. We refer to this as a limitation in their
development. There are many reasons for this
limitation. The limit is now a behavior that can be
treated—Not a forever label.”
Suzanne Evans Morris
During feeding, poor oral-motor skills may lead to:
• Gagging/frequent choking
• Drooling
• Difficulty keeping food down
• Difficulty transitioning to different textured foods
• Difficulty sucking, chewing, swallowing
• Picky eating habits (avoiding textures, temperature,
tastes)
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Copyright 2014 Ernsperger
Low Muscle Tone
Treatment Strategies: Oral Motor
• Tongue
– Reduces strength for safe eating
– Reduces sustained chewing
– Pockets food
• Cheeks and lips
– Limited facial movement
– Mouth to hang open
– Drooling
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Oral awareness and oral stimulation
Mouth Madness by Catherine Orr
“Can Do” Oral Motor Cards (www.superduperinc.com)
Oral-Motor Activities for Young Children
(www.linguisystems.com)
• Mouth Box
– Rubbermaid container
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Caution
• Never enter a child’s
mouth without being
highly qualified and
highly effective
• Appropriate
credentials, licensed,
and on-going training
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Mouth-Toys
for Resistant Eaters
• Appropriate for all ages
– Action figures
– Select items designed for chewing
• Sensory discrimination
– Textures
• Oral-motor awareness
• Use mouth toys to introduce new foods
• Teaches oral-motor coordination
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Oral Motor Skills
• Phases of Swallowing
– Oral Phase- 2 parts
– Pharyngeal phase- movement of the bolus
– Esophageal phase- to the stomach
• Cracker Activity
– Texture
– Tongue Control
– Placement
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TX: Stretchy Tubing
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Sensory feedback
Biting
Chewing
Jaw stabilization
Sucking
Dip into a variety of
flavors
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Copyright 2014 Ernsperger
Respiration and Eating
Tx: Blowing Activities
You can’t eat if you can’t breathe
Nasal cavity, trachea, lungs
Breathing, swallowing, and talking
Coordination
Important when feeding a child- pace of the
meal
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Bubble Blower
Birthday horns
Straws and cotton balls
Practice deep breathing
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Caution:
Chewing Activities
• Dental Check
• Tina’s first dental check
Autism Speaks Dental Tool Kit
www.autismspeaks.org
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Sensory Based Eating Challenges
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The following is a brief overview
Work within your competency
Experts in the field of OT
Scientifically based research published in peer
reviewed journals
Sensory-Based Eating Challenges
• Dr. A Jean Ayres- pioneer in OT
• Our brain:
– Receives sensory information from our bodies and
surroundings
– Interprets these messages
– Organizes a purposeful response
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Proprioceptive System & Mealtimes
 Definition
 Adjusting/grading jaw opening
 Hold utensils with too much/too
little force
 Knowing body position in relation
to objects on table
 Grading movement to drink
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Weighted utensils
Weighted drinking cup
Crazy Straws
Thicken liquids
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Copyright 2014 Ernsperger
Vestibular System & Mealtimes
Gustatory System & Mealtimes
• Definition
• Focus all attention on
moving sensations
• Quick movement – alerting
• Slow movements - calming
• Muscle tone
• Max
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 Decreased taste sensitivity
(inedible objects, spicy
foods, extreme
temperatures)
 Increased taste sensitivity
(object to
textures/temperatures, gag)
 “Supertasters”
 Medications can change
tastes
 Sweet-tasting addiction
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Olfactory System & Mealtimes
 75% of taste perceptions
depend on efficient sense
of smell
 Olfactory stimulus goes to
the limbic system (emotions
and inner drive) – strong
association with memory
storage
 Odor & childhood memory?
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Auditory/Visual
 Calming visual input:
dull finish utensils
lighting
table setting
 Music with a slow tempo,
and regular sustained
rhythm slows down
breathing and heart
rhythms – lead to relaxation
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Tx: Olfactory
• Food at room temperature
• Limiting number of smells
• Calming activities:
blowing
proprioceptive input
drinking water
sucking on ice
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Review
• Highly qualified professionals to assess for oralmotor and sensory based feeding challenges
• Multidisciplinary teams
• Parental involvement
• Combination approach must include Behavior
Intervention Plan
– Behavioral difficulties interfere with mealtimes even
after physiological issues have been addressed
• “The Perfect Meal” review
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Principles of ABA
abainternational.org
Feeding Behavior Intervention Plan
Antecedent
Behavior
Consequence
ACTION PLAN
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 Based on principles of
behavioral learning theory
 Based on behavioral
determinism, behavior does
not occur randomly, it is
predictable and lawful and
follows a set of scientific
principles
 Data based decision making
 Based on socially significant
behaviors that will improve
the outcome for the
student
 An emphasis on reinforcing
appropriate behavior rather
than punish inappropriate
behavior
 Focus on observable
behaviors that are clear and
concise
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ABA: Three Term Contingency
Functional Behavior Assessment
• Functional Behavior Assessment
(EBP)
• FBA focuses on investigating the
nature of the target behavior.
• As a team, we must ask
ourselves “why?” is the child
exhibiting this behavior at
mealtimes?
• What purpose does the
behavior serve for the child?
Copyright 2014 Ernsperger
Copyright 2014 Ernsperger
Steps to completing a
FBA and BIP
Feeding Plan
1.
2.
3.
4.
5.
6.
7.
Antecedent Based Interventions
• Assess antecedents which are currently
maintaining behavioral challenges at
mealtimes
• Too much food?
• Portion Size?
• Mealtime Environment
• Interview parents
Identify the Target Behavior
Data Collection
Develop a Hypothesis
Write the BIP Teach Replacement skills
Modify Antecedents and Environment
Identify Reinforcement
Evaluate Plan; progress monitoring
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Ernsperger
Antecedent Based Interventions
 Role of the family
 Family schedules, settings, and
serving sizes
 Problem behaviors reinforced
with attention by parents
 Lack of knowledge and
awareness of interfering
problem behaviors
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Copyright 2014 Ernsperger
Parental Responsibility
• Myth: Good parents are responsible for getting their
child to eat.
– “Parents and professionals working with children
are responsible for preparing and providing a
balanced meal at an appropriate schedule and
setting. The CHILD is solely responsible for
whether they eat and how much they eat.”
– Ellyn Satter, Secrets of Feeding a Healthy Family
Copyright 2014 Ernsperger
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Antecedent
Mealtime Activity
“Guess Who’s Coming to Dinner”
List 4 Beliefs you have in your family about
eating
• How do you feel about mealtimes
• Your role and responsibility
• Personal beliefs about meals and food
• Generational rules
Environment
Positioning
Rules and Routines
Visual Supports
Social Narratives
ANTECEDENT –B - C
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Copyright 2014 Ernsperger
ABI: Visual Supports
• Schedule
ABI: Organize Environment
Create a Consistent Setting
– Written and posted
◦ Eating and drinking is done at
the table
◦ Supportive and nurturing
• Understandable to
the child
– Timers
– Includes snacks
– No grazing and only
water between
meals
 Role model good eating habits
 Do not discuss the child’s eating
habits during the meal
◦ Limit distractions
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Ernsperger
ABI:
Portion Size and Food Selection
 Food selection
◦ Always have one preferred food item at
every meal
 The preferred item is the prompt
 Fade prompt over time
◦ Pair a new food with a preferred food
◦ Child-friendly foods
◦ Temperature
 Portion size
◦ Age appropriate plates and utensils
◦ Measuring spoons and cups
◦ Less is best
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Copyright 2014 Ernsperger
Food Selection: How to Choose?
• Resistance
– Graham cracker v. bagel
• Sensory Input
– Pickles v. mild cheese
• Size
– Small pretzel v. sandwich
• Shape
– Veggie stixs v. toast
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“The mouth and body interact in
partnership to support sufficient
eating. The way in which a person
moves the body, makes a big
difference in the way in which the
mouth moves for eating.”
Suzanne Evans Morris
www.new-vis.com
Copyright 2014 Ernsperger
Tx: Behavior and Mealtimes
• Check environmental factors
• Set a routine pre and post meal
– Transition activities-auditory
– Involve child in pre-meal
activities
• Written rules
– Teach routines
• Stick with the schedule
ABI:
Positioning
 Consult with an OT
 What position is the trunk?
 How are the shoulders
supported?
 What type of head control?
 What supports for the hips
and pelvis?
 Do the feet have adequate
support?
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Social Narratives (EBP)
Select a clear goal or desired outcome
Write in the first person
Use Wh questions as an outline
Write positive behaviors and outcomes
Visual and concrete information
Consider a student’s cognitive level
Provides the individual with the opportunity to practice
a new or difficult behavior
Include already acquired skills (strengths)
Antecedent Strategy
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Write a Social Narrative
• Answer the W
questions
• What are the
observable and
measurable behaviors?
• Positive Outcome
• Share with group
• Review EBP Checklist
• Share with group
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Copyright 2014 Ernsperger
Teach about Foods
 Food Rich Environment
◦ repetition
 Teach the child about
the food pyramid
 Sort foods by colors
 If they know moreThey will eat more!
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Antecedent:
Teach Mands
Requesting Skills
• Review Feeding BIP
– Does it include teaching the child to request
• Teach requesting skills
– Basic communication needs
• Functional Communication Training
– EBP
• Verbal Behavior:
– Skinner
1. Manding pairs the adult with the delivery of food specific to
the mand. (preferred food item or reinforcer)
2. Manding is essential for social communication at mealtimes
interaction.
3. Manding is verbal behavior that produces immediate benefit
for the student and strengthens it.
4. Development of a strong manding repertoire may be essential
for the development of other types of verbal behavior (ex.
tacting, intraverbal, etc.). Manding teaches a student that
behavior is valuable
• What is a mand?
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Interventions Implemented During
Treatment/Mealtime
• Shaping
– Task Analysis of Steps to Eating
During Mealtimes
Interventions at mealtimes
Introducing new foods
Compliance and High-P Programs
A- BEHAVIOR - C
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Kay Toomey SOS Approach
30 Steps to Eating
Being in the room with a new food
Chewing and swallowing independently
“Just Try It!”
Re-define “trying”
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Copyright 2014 Ernsperger
Naturalistic Interventions:
Introducing New Foods
• Prompt and prompt fading
– Preferred foods are a prompt to be paired with
the new food item
– SD plus prompt
• Modeling
• Children learn to eat through their senses
– Developmentally appropriate practices
• Playful and fun
– Naturalistic behavioral Interventions (EBP)
– Child-centered as much as possible
• 10-15 successful trials at each stage
– Visual models
– Adult models
– Peer models
– Video Modeling
– Systematic desensitization
– How do we learn about new foods?
• Grace
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10
Non-Compliance at Mealtimes
Intervene with a High-P Program
• Noncompliance and escape behavior are
learned
• Intervene at first signs of non-compliance or a
“negative tilt”
• High-probability programs focus on mastered
skills
• What skills or behaviors can the student easily
master?
• Rote Memory
• 2+2 =?
• Receptive labeling
– Marsha Dunn Klein
• Review crisis cycle
– “Touch Nose”
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High - P
A-Behavior-C
Steps for High-P Program
 Examples of High-P program
• Intervene at first signs of noncompliance
 Case Study
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◦ Compliance Form
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– trigger
Student at recess- ESY
What is the probability of compliance?
Identify 3-5 mastered skills
Receptive Labels:
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Touch Cinderella
Touch Jasmine
Touch Bell
Touch Tiana
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Have materials accessible
Give instructions clear and concise
Reinforce
Rapid 3-5 high-p instructions followed by lowprobability command (stand-up)
• If non-compliance continues; repeat instructions
and increase reinforcement
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Negative Reinforcement
Negative Reinforcement
Escape Extinction
Positive Reinforcement
Data Collection
A – B - CONSEQUENCE
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• Removal of an non-preferred or aversive (new
food) which maintains future rates of behavior
• Student’s behavior at mealtimes has been
maintained or increased over time based on
reinforcement for leaving the meal
• Attention from parents or other adults
• Escape from food
• Preferred foods are provided at a later time
not on the schedule
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Escape Extinction at Mealtimes
Part Three: Consequence
• Three Term Contingency
• Data based decision with IEP team
• Competency: area of expertise
– A-B-C
– Focus on the Consequence
– Difficult for parents
• School district policies: restraint?
– Blocking a student from escaping
• Review high-probability and identify compliance
levels
• Carefully monitor level of compliance
• Teach student to request a break
• Compliance at mealtimes behaviors will only
repeated if they are immediately followed by
reinforcement
• Reinforcement increases the likelihood for the
student to exhibit compliant behaviors in the
future at mealtimes
• Preference Assessment vs. Reinforcement
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Part Three: Reinforcement
Consequence: Reinforcement
• Rules for reinforcement
 Schedule of reinforcement
– No edible reinforcement
• Rotate reinforcement
• Select the most powerful reinforcement for
compliance program
• Reinforcement is not bribery
• Change your TV viewing behavior?
◦ Immediate vs delayed
◦ Reinforce all levels of the food hierarchy
◦ Deprivation is a “good thing”
 Token Economy
◦ How many? How often is the exchange?
 Picture Token Boards
◦ Computer
– Stop watching your favorite shows?
– How much money?
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Data Based Decisions at Mealtimes
Mealtime BIP
Data collection
• Collect Data
• Graph Data
– Aimline
• Determine if the target behavior has
decreased and/or
• Has the alternative or replacement behavior
increased
• Analyze the quality of the reinforcer
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Ernsperger
• Duration: how long at mealtimes?
• Frequency or rate: Number of Bites
– Golf counter
– Hand-counter
– Masking tape
– Pennies
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Aimline: Connect Baseline with IEP Goal
Independent Bites: Goal = 4
Data Analysis
• Data driven decision making
• After three data points, determine:
– Is the child meeting the goals?
– If YES, proceed with mealtime interventions.
– If NO, make changes to mealtime environment,
schedule, reinforcement, antecedents
– Self-reflection
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Review Mealtime BIP
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Oral-motor and sensory based plan
Mealtime Behavior Intervention Plan
Data Collection?
Long-term goals
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13
Mealtime Behavior Intervention Plan
A
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Antecedent
Context
Mealtime environment
Before the behavior occurs
Therapy environment
B
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Observable
Measurable
Specific
Target behavior at mealtimes
or during therapy
C
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Consequence
After the behavior occurs
Function of behavior
Adult reaction to child’s
behavior
Hypothesis Statement: (When this occurs …/The child does …../In order to ….)
_______________________________________________________________________________
_______________________________________________________________________________
Antecedent Based Interventions: mealtime environment, visual supports:
1.
2.
3.
Preference assessment:
1.
2.
3.
Replacement or Alternative Skills: Request a break, functional communication
1.
2.
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Food Neophobia Scale
Pliner & Hobden
*Mark the following when answering items 2, 3, 5, 7, & 8
1=disagree extremely
2=disagree moderately
3=disagree slightly
4=neither agree nor disagree
5=agree slightly
6=agree moderately
7=agree extremely
*Mark the following when answering items: 1,4,6,9, & 10 (bold and italics)
1=agree extremely
2=agree moderately
3=agree slightly
4=neither agree nor disagree
5=disagree slightly
6=disagree moderately
7=disagree extremely
____ 1. I am constantly sampling new and different foods.
____ 2. I don’t trust new foods
____ 3. If I don’t know what is in a food, I won’t try it.
____ 4. I like foods from different countries
____ 5. Ethnic food looks too weird to eat.
____ 6. At dinner parties, I will try a new food.
____ 7. I am afraid to eat things I have never had before.
____ 8. I am very particular about the foods I will eat.
____ 9. I will eat almost anything.
____ 10. I like to try new ethnic restaurants.
* If parents are rating their child, change each item to include “my child”
References and Resources
Lori Ernsperger, Ph.D., BCBA-D
[email protected]
Just Take a Bite: Easy, Effective Answers to Food Aversion and Eating
Challenges (2004). Lori Ernsperger & Tania Stegen Hanson.
1.
Pre-Feeding Skills, A Comprehensive Resource For Mealtime Development, 2nd
edition (2000). Suzanne Evans Morris, PH.D., CCC-SLP and Marsh Dunn Klein, M.ED.,
OTR/L. Therapy Skill Builders. www.new-vis.com
2.
The Out-Of-Sync Child Carol Stock Kranowitz, M.A. Future Horizons.
3.
The Out-Of-Sync Child Has Fun Carol Stock Kranowitz, M.A. Sensory
Resources.
4.
How to get Your Child to Eat, But Not Too Much, (1987). E. Satter, Bull
Publishing.
5.
Secrets of Feeding a Healthy Family (1999). E. Satter, Kelcy Press.
6.
Normal Development of Functional Motor Skills, Rona Alexander, Ph.D., CCCSP; Regi Boehme, OTR and Barbara Cupps, PT.
7.
Mouth Madness: Oral Motor Activities for Children, (1998). Catherine Orr,
M.A., OTR. Therapy Skill Builders.
8.
Pliner and Hobden (1992). Development of a Scale to Measure the Trait of Food
Neophobia in Humans, Appetite, v. 19.
9.
North American Society for Pediatric Gastroenterology, Hepatology and Nutrition
www.naspgn.org, 215-333-0808.
10.
Applying Sensory Integration Principles Where Children Live, Learn, and Play:
www.sensoryresources.com (video)
11.
www.usda.gov, US Department of Agriculture and www.choosemyplate.gov
12.
Dole Company, Five a day Program: On-line catalogue for educators.
www.5aday.com.
13.
The Educators Guide to Feeding Children with Disabilities, Lowman & Murphy.
Paul H. Brookes Co., www.pbrookes.com.
14.
NCES catalogue of nutrition and education resources: www.ncescatalog.com.
15.
Abilitations Catalogue: products specializing in positioning and oral motor
development. www.abilitations.com.
16.
Keys to Success for Teaching Students with Autism (2003). Ernsperger, Lori.
Future Horizons Publishing.
17.
Childhood Feeding Disorders, Kedesdy & Budd (1998). Paul Brookes Pub.,
www.brookespublishing.com.
18.
Oral-Motor Activities for Young Children (1996). Mackie, E. Linguisystems Inc.
www.linguisystems.com
19.
Therapro: www.theraproducts.com
20.
Food Chaining (2007). Fraker, Fishbein, Cox, and Walbert. Da Capo Press.
21.
Get Permission Approach (video) with Marsha Dunn Klein.
www.mealtimenotions.com
22.
Talk Tools Catalogue www.talktoolstm.com
Eating Profile - Brief
Name: _______________________________________ Age: ___________________
Accepted Foods; Preferred foods; Selective Brands; Utensils; Other Rituals (Include Food
Jags):
Preferred Textures, Colors, Flavors:
Sensory Issues:
Other Medical Issues (GERD); diagnosis:
Physical Limitations (include oral-motor delays); Assessment data:
Medications and Side-Effects of Medicine:
Parental Concerns:
Goal Statement of Feeding Program: